Reimbursement Issues for Nurse Practitioners

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Table of Contents

Introduction
Summary
Key Reimbursement Issue
Ethical and Legal Implications
Conclusion
References

Introduction

Managed care organizations (MCOs) offer a great opportunity for nurse practitioners (NPs) to serve as primary care providers in their area. MCOs create a network of specialists and services for patients while also giving clinicians a system with credentialing, negotiable contracting, and patient flow (Buppert, 2018). Nonetheless, the status of a primary care provider entails a certain degree of responsibility for the quality of care, and some MCOs do not want to or cannot work with NPs for this reason. The chosen article presents findings of MCOs’ choice to employ NPs in the United States, discussing the issues of individual policies, unclear standards, lower reimbursement rates, and ethical concerns.

Summary

The selected study discusses whether NPs still encounter berries when applying to an MCO. Bellot et al. (2017) conduct interviews with several organizations from different states to determine their attitude towards working with nurses as well as their reimbursement rates, policies, the scope of practice, and other aspects of collaboration. As a result, the authors find that about a quarter of all contacted MCOs do not work with NPs as primary care providers.

These entities keep restrictive policies in place due to either their location or individual arguments. Moreover, Bellot et al. (2017) note that MCOs’ rate of contracting NPs has not been increasing in the last several years. They also show that many of these organizations limit NPs’ access to Medicaid patients. Finally, NPs often earn less than physicians through MCOs, although they perform the same operations, and there is a major shortage of physicians in several states.

Key Reimbursement Issue

One of the issues discussed in the article is the limited collaboration between NPs and MCOs in areas where safety-net clinics are popular among patients. In collaborative practice, NPs can be a part of a clinic that attracts more attention from an MCO. However, nurses often operate in an independent practice on a tight budget, and their patients are vulnerable to any price changes or new expenses (Keast, Skrepnek, & Nesser, 2016).

The scholars argue that MCO’s lack of effort to work with these NPs has a negative effect on patient’s bills as well as nurses’ quality of care and job assurance (Bellot et al., 2017). Dugan (2015) highlights the role of MCOs in cost containment, which aligns with the ideas presented by the discussed article. NPs can provide many benefits to patients and organizations as primary care providers, which shows that restrictive policies limit people’s access to affordable care.

Ethical and Legal Implications

Nursing practice is viewed differently in each state, and this variety leads to many legal issues for MCOs. In some states, NPs cannot be recognized as primary care providers, which explains MCO’s refusal to review their own and governmental policies. Nevertheless, organizations in states where NPs are allowed to practice independently also expressed their hesitance about contracting NPs. According to Bellot et al. (2017), some reasons include limited understanding of NPs’ scope of knowledge and practice and hierarchy-based prejudice. Thus, nurses have to advocate for themselves on a governmental and corporate level.

Conclusion

MCOs have some benefits for patients and providers, but their reluctance to work with NPs poses problems for both sides as well. Geographic differences in law are not the only barrier that NPs face when applying to an MCO. Misconceptions about nurses’ abilities as primary care providers limit their access to high reimbursement rates, patients with fewer finances, and a network of specialists. The article reveals many ethical and legal issues that have to be resolved to improve the quality of care in the US.

References

Bellot, J., Valdez, B., Altdoerffer, K., Quiaoit, Y., Bronzell-Wynder, T., & Cunningham, P. (2017). Does contracting with managed care organizations remain a barrier for nurse practitioners? Nursing Economics, 35(2), 57-63.

Buppert, C. (2018). Nurse practitioner’s business practice and legal guide (6th ed.). Sudbury, MA: Bartlett & Jones Learning.

Dugan, J. (2015). Trends in managed care cost containment: An analysis of the managed care backlash. Health Economics, 24(12), 1604-1618.

Keast, S. L., Skrepnek, G., & Nesser, N. (2016). State Medicaid programs bring managed care tenets to fee for service. Journal of Managed Care & Specialty Pharmacy, 22(2), 145-148.

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Reimbursement Issues for Nurse Practitioners

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